ASSIST Legacy Webinar Series Strengthening Health Systems to Achieve Better Outcomes Strengthening systems to prevent antimicrobial resistance: Results from the West Bank, Uganda, and Georgia March 28, 2018 The webinar will begin momentarily; during the webinar, please type your questions for the speakers in the Chat box. 1
Welcome from the Webinar Moderator Mirwais Rahimzai, MD, MPH Regional Director, East Africa USAID ASSIST Project University Research Co., LLC 2
Today s speakers Tamar Chitashvili, MD, MHP&M Senior Quality Improvement Advisor, Maternal and Child Health and Non-communicable Diseases USAID ASSIST Project, URC Lisa Dolan- Branton, RN, MPH Senior Quality Improvement Advisor USAID ASSIST Project, URC Garance Fannie Upham Vice President World Alliance Against Antibiotic Resistance Editor in Chief, AMR Control 3
Global problem of antimicrobial resistance (AMR) AMR is rising to dangerously high levels New resistance mechanisms, spreading globally & threatening our ability to treat common infectious diseases. Worsened health outcomes Higher cost for payers and the society The pipeline for new tools to combat drug resistance is almost dry, WHO 2017 Common challenges Inappropriate use and prescription Poor infection prevention and control Weak surveillance Limited new tools/ Insufficient use of existing mechanisms 4 WHO, World Health Day, 2011
WHO Global Action Plan on AMR Goal: To ensure, for as long as possible, continuity of the ability to treat and prevent infectious diseases with effective and safe medicines that are quality-assured, used in a responsible way, and accessible to all who need them. Improve awareness and understanding of antimicrobial resistance Strengthen knowledge through surveillance and research Reduce the incidence of infection Optimize the use of antimicrobial agents Develop the economic case for sustainable investment in countering antimicrobial resistance 5
ASSIST s key strategies to strengthen systems to prevent AMR Enhance capacity in quality improvement (QI), data analysis and use for evidence-based decisions Generate evidence on effectiveness and costeffectiveness of rational prescription of antibiotics Leadership/ Management Build capacity: clinical knowledge and skills, QI, and using evidence-based clinical recommendations in surveillance of AMR and rational antibiotic practices Enhanced teamwork and group problem-solving Human Resources Improve generation, regular collection, analysis, reporting, and use of quality clinical/nonclinical data for continuous QI to improve IPC, AMR surveillance, and rational antibiotic use Information Systems Improve compliance with evidence-based care practices (content) and organization of health service delivery (process) for common childhood conditions and IPC measures Service Delivery Improve prescribing & use of recommended medicines and reduce prescription and use of not- recommended antibiotics or route of administration and suboptimal dosage Medicines/ Supplies Reduce cost of treatment by rational use of antibiotics (1 st choice, generics, optimal dose and route) and reduce inefficiencies in process of care Focus on high-impact, costeffective interventions for high burden/mortality conditions Financing 6
Three applications of improvement methods to reduce AMR West Bank improvement collaborative with 22 public and private hospitals to reduce hospitalacquired infections (HAI) Improve Integrated Management of newborn and Childhood Illness (IMNCI) in 10 facilities in Northern Uganda Improve outpatient and hospital management of childhood respiratory tract infections (RTI) in 19 health facilities in Georgia 7
WHO Action Plan Objective 1: Improve awareness and understanding of antimicrobial resistance through effective communication, education and training 8
Goals of the West Bank HAI collaborative Institutionalize a system to control HAIs across 22 hospitals in the West Bank by Sept 30, 2017 9
Collaborative methodology Learning sessions: Three 2-day hospital clinical QI, leadership and lab track sessions (February, May, August) Video calls (ECHO) & YouTube Channel Lab track: 7 calls with an average 17.4 Hospitals Hospital QI track: 14 calls with an average 15.3 Hospital AMS: 5 mos series for MDs and PharmDs Coaching visits Hospital QI teams: 70 visits (February- July) Laboratory Track: 18 visits (April-July) Practical skills training Shadowing expert microbiologists by Micro Lab Techs (21 total) Shadowing expert MDs/PharmDs with active antibiotic management programs (20 total) 10
WhatsApp Laboratory group Extremely dynamic and active WhatsApp group All microbiology members are on this group We consult with each other Share interesting growth of bacteria Share interesting cases 11
WHO Action Plan Objective 2: Strengthen the knowledge and evidence base through surveillance and research 12
Improved QI data collection and use by hospital teams in the West Bank Data collection and Submission February: 11 hospitals submitted March: 19 hospitals submitted April: 20 hospitals submitted May: 22 hospitals submitted June: 20 hospitals submitted 13
Antibiograms for every hospital and the system as a whole in the West Bank 14
WHO Action Plan Objective 3: Reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures 15
Changes to improve hand hygiene in the West Bank Infrastructure Deploying alcohol gel Posting signs and posters Finding partners to help adapt infrastructure to build sinks Updating engineering plans for renovations Data Accurately measuring compliance through careful observation Gathering data by discipline and ward Sharing & publicly posting data Workforce Training staff on optimal handwashing technique & required moments of hygiene Educating & engaging families and visitors Working with nursing students to help with data collection, education, and reminders Rewarding staff for high rates of compliance Leadership working with physicians 16
Improvements in hand hygiene processes and outcomes in the West Bank (Feb-June 2017) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 20 15 10 5 0 17 % compliance with hand hygiene indicators over time, Feb June 2017 Feb 17 Mar 17 Apr 17 May 17 Jun 17 Number of facilities reporting data % sinks with running water % sinks with liquid soap % sinks with paper towels % of work areas with alcohol rub available in plain sight % compliance with hand hygiene
Improvements in transmission-based precautions and outcomes in the West Bank (Feb-June 2017) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 15 10 5 0 18 Improvement in transmission based precautions, Feb June 2017 % patients in contact isolation visibly identified as in isolation Feb 17 Mar 17 Apr 17 May 17 Jun 17 Number of facilities reporting data % patients in contact isolation with protective gloves available at the barrier % patients in contact isolation with single use aprons/gowns available at the barrier % patients in contact isolation with waste bag/waste container available at the barrier % patients in contact isolation with alcohol rub or hand washing facilities available at the barrier or in sight of the barrier % isolated patients with all 5 components of TBP process in place
Country-wide standardization of patient isolation, PPE & hand hygiene methods 19
WHO Action Plan Objective 4: Optimize the use of antimicrobial medicines in human and animal health 20
Inappropriate prescription of antibiotics is widespread in different settings Inappropriate prescription of antibiotics to treat common childhood conditions (use without clinical indications, use of non- 1 st or 2 nd choice antibiotic, incorrect dosing and/or route) Poor assessment and classification practices Poor knowledge and skills to diagnose and manage common childhood conditions Limited availability of 1 st choice antibiotics, including recommended dosage and form Misconceptions among careers of the need to prescribe multiple medications, including antibiotics to treat common childhood conditions Baseline Findings Antibiotic prescription practice 1 st line antibiotic Pneumonia RTI Recommended dosage (w/age) Pneumonia RTIs Unjustified antibiotic for URTI/cough or cold Diarrhoea Malaria Route: Parenteral (outpatient) Geo 36% 8% 75% 39% Ug 42% 0% 46% 83% 55% 34% 23% 21
Poor assessment and classification practices in Uganda (direct observation of > 770 OPD visits, children 2m-5 years) Indicators IDENTIFIED GAPS Poor standardization and completeness of medical documentation for using data for quality improvement Limited availability of scales and thermometers Limited time of care providers Limited knowledge of signs and symptoms of common conditions TESTED CHANGES Establishing the triage places for sick children Involve village health workers in assessment of vital and danger signs Adapted registers to document essential data for clinical decisions (e.g.rr, temperature) Peer clinical review and feedback by experienced staff Developed and displayed job aids Bi-weekly coaching by district staff Baseiine intervention N=212 % (n) 0% (0) Endline control N=295 % (n) Endline Intervention N=271 %(n) 45% (134) Children assessed for three general danger signs 0% (able to drink/bf, vomits everything, has convulsions) Assessment of three main symptoms (cough, diarrhea and fever) 22% (47) 32% (86) 93% (273) Vital signs RR assessed in children with respiratory problems 15% (27) 2% (3) 82% (176) o Temperature measured 33% (71) 20% (53) 97%% (286) o Stiff neck (if fever) 0% (0) 0% (1) 59% (115) o Weight measured USAID Applying Science 21% to (45) 42% (113) 100% (293) Strengthen and Improve Systems IMCI SOURCE: based USAID diagnosis ASSIST Project, Uganda, 2017 21% (44) 10% (28) 81% (238)
Correct classification is essential for better antibiotic prescription practices: change from broad RTI diagnosis to proper classification and treatment of cough or cold (Uganda) Baseline (Jan 2016) End Line (Nov 2016) 6% 10% 5% 9% 7% 4% Cough or Cold Respiratory Tract Infection (RTI) Upper Resipatory Tract Infection (URTI) Intervention 11% 19% 49% 80% Accute Respiratory Tract Infection (ARI) RIT Malaria Other Control 24% Baseline 5% 3% 25% 3% 8% 5% End Line 29% Antibiotic treatment for cough and cold or RTI reduced by 56% compared to control facilities from the baseline (p<0.0001) 43% 54% 23
Addressing gaps in poor knowledge and skills of care providers Uganda % of providers who correctly answered questions Endline Outpatient care of severe pneumonia Care of Diarrhoea with no dehydr Indications of antibiotics for Diarrhoea Outpatient care of fever Recommended care for cough or cold Care for young Infants with PSBI Georgia all 4 questions on RTI care Baseline 0% 0% 6% 4% 31% 38% 75% 96% 96% 92% 88% 100% 100% 97% 0% 50% 100% Groupwork, case study discussions: Uganda IDENTIFIED GAPS Poor knowledge and skills in evidence-based diagnosis and care; limited understanding of signs/symptoms of specific clinical conditions Poor knowledge and skills to search, apprise and use medical literature TESTED/IMPLEMENTED CHANGES Developing/distributing job aides Needs-based on-job clinical and QI trainings, coaching Peer-review of medical documentation, case presentations, case review, directly observed consultations Non-financial/promotion incentives for high performing providers Internal clinical supervision by experienced staff Organizing workshops for other care providers Translating research into Practice (TRIP) trainings Utilizing videos, developed by Global Health Media Project Direct-observed consultations and feedback: Georgia 24
Improved antibiotic prescription practices in Georgia Outpatient Inpatient EB antipyretic practices (acetaminophen or ibuprofen if t>38.50c) 5 % 32% *** EB antipyretic practice (acetaminophen or ibuprofen if t>38.50c) 31% 63%*** Antibiotics prescribed in guideline recommended dosage % of charts with Aminopenicilins prescribed evidence-based first-line antibiotic use 38% 32%* 17% 32%* 8% 71%*** Antibiotics prescribed in guideline recommended dosage % of charts with aminoglycosids prescribed 69% 17%** 43% -34%*** Justified antibiotic use 19% 68%*** Evidence-based first-line antibiotic use 36% 33%*** baseline(inter vention) attributable difference 25 0% 50% 100% *** P<0.0001 0% 50% 100% Baseline and attributable improvement in management of RTIs at ambulatories (n=212 random charts) and hospital management of pneumonia (n=274 random charts)
100% Rationalized prescription practices for treatment of common childhood conditions, Uganda % of children 2mo 5yrs with pneumonia to whom first line antibiotic was prescribed % of children 2 mo 5yrs with a classification of cough or cold to whom an antibiotics is prescribed % of children 2mo under 5 years with malaria, treated with concurrent unjustified antibiotics therapy % of children under 5yrs with a diagnosis of diarrhea, where antibiotics or other non EB treatment is prescribed 10 sites, n=300 80% 60% Antibiotic for cough or cold 1st line antibiotic for pneumonia Antiobiotics for malaria Improvement in intervention sites compared to control sites in correct dosage of 1st line antibiotic is +80%, P<0.0001 40% Non EB treatment for diarrhea 20% 0% Jul 15 Aug 15 Sep 15 Oct 15 Nov 15 Dec 15 Jan 16 Feb 16 Mar 16 Apr 16 May 16 Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 26
Improved access/availability of essential medications in Uganda Indicators Baseline intervention (Jan 2016) n=10 End line control (Mar 2017) n=10 End line intervention (Mar 2017) n=10 Availability of Ampicillin (IM or IV) 75% 30% 100% Number of stock out days per month in facilities with stock outs 30 18 0 Amoxicillin (Oral) Number of stock out days per month 90% 30 70% 17 60% 15 Availability of Gentamicin (IM or IV) Number of stock out days per month 100% 40% 22 100% 0 27
Addressing misconceptions and appropriate use of antibiotics by caregivers IDENTIFIED GAPS Misconceptions among parents of the need to prescribe antibiotics to treat pediatric RTIs Inappropriate use of antibiotics (sold over the counter) by caregivers TESTED CHANGES Educating and counselling parents on correct administration of the antibiotics Counselling careers on rational antibiotic use at every visit Posters on rational antibiotic use Discussing the issue at medical conferences, meetings, shared success efforts Shared the communication massages via local media and TV by wellrespected clinicians, including heads of respiratory association I was afraid to see my ill child suffering and not give him antibiotics. Now I know that antibiotics are dangerous when not needed. Indicators Uganda: Education of caregiver on administration of antibiotics Explained Demonstrated Explained correct administration of anti malarials Georgia: improved knowledge and practice of caregivers on antibiotics use during RTI Patients without prescription of any irrelevant antibiotic Per os route of antibiotic Baseline intervention 41% (69) 34% (69) 20% (14) 3%(2) 77% (40) End line control 2% (3) 1% (1) 7% (5) 2% (1) 78% (30) End line Intervention 100% (147) 64% (49) 100% (96) 31%(10) 93%(14) End line Control 8% (5) 70% (21) 28
WHO Action Plan Objective 5: Develop the economic case for sustainable investment that takes account of the needs of all countries and increase investment 29
Economic evaluation of child care improvement interventions in Georgia and Uganda Country Clinical conditions # of patients Total cost in USD Cost saving per patient Total cost saving in USD Georgia RTI amb 26236 22,484 4.9 127,802 Pneumonia hosp 1544 14,989 12.1 18,614 Subtotal 37,473 146,416 Uganda cough or cold/rti 45,621 2,146 0.13 5820 Pneumonia 10,841 2146 0.03 302 Malaria 120,768 2,146 0.02 3006 Diarrhoea 16,502 2,146 0.05 823 Subtotal 8,584 9,951 Uganda: ICER per improved abx prescription practices ICER/USD Rationalized antibiotic prescription for cough and cold 0.08 Pneumonia treated with adequate dosage first line antibiotic 0.25 EB treatment of Diarrhoea without concurrent abx 0.30 Evidence based treatment for PSBI, including initial treatment 3.14 and referral or full outpatient treatment ICER does not include cost of compliance or non-compliance, including economic effects of unsafe use of Abx, AMR etc. 30
Discussion with Garance Upham, Tamar Chitashvili, and Lisa Dolan-Branton Participants should use the chat function to post questions (send to All panelists ). Responses to questions not addressed during the webinar will be posted afterwards on: https://www.usaidassist.org/content/legacywebinar-series-preventing-antimicrobial-resistance-west-bank-ugandageorgia 31
Closing Remarks Mirwais Rahimzai, MD, MPH Regional Director, East Africa USAID ASSIST Project University Research Co., LLC 32
Resources to learn more: www.usaidassist.org/content/legacy-webinar-series-preventingantimicrobial-resistance-west-bank-uganda-georgia AMR CONTROL 2017: Using quality improvement to address hospital-acquired infections and antimicrobial resistance Improving rational antibiotic treatment of common childhood conditions in Uganda Embedding quality improvement through a learning collaborative to reduce and sustain hospital-acquired infections in the West Bank The Economics of Reducing Antibiotic Use to Reduce Antimicrobial Resistance Improving Integrated Management of Newborn and Childhood Illnesses in Northern Uganda. Int J Integr Care 2017 Rationale for improving integrated service delivery: reduced cost and improved care in Georgia. Int J Integr Care 2015 West Bank HAI Collaborative Tools 33
ASSIST Legacy Webinar Series Strengthening Health Systems to Achieve Better Outcomes Upcoming webinar: Strengthening the power of the OVC platform to achieve epidemic control through community linkages Wednesday, April 25, 2018 9:00-10:00am Register at: https://zoom.us/webinar/register/wn_fy-5qy0zrgop3kkj4o6wrg 34